CLEVELAND, Ohio - For years, registered nurses at the Franklin Medical Center, the state's prison hospital, have worked tens of thousands of hours of overtime caring for Ohio's sick and dying prison inmates.

One of them, Joshua Ndematebem, earned $222,988 last year. More than half of that, $114,772, was overtime pay, records show. In fact, because of the overtime, he made more money than his boss, Gary Mohr, the director of the prison system, who earned $143,700.

The prison nurses' workload underscores a growing problem that hits Ohio taxpayers in the wallet: Overtime for state employees has increased 20 percent since 2012. At the same time, extra pay for registered nurses has jumped nearly 60 percent, according to a Plain Dealer analysis of payroll records.

The higher costs come as the state struggles to find and retain qualified nurses to care for the increasingly aging prison population, according to interviews and budget estimates.

"There is a horrendous amount of overtime,'' said a nurse who retired from the state prison system recently and declined to be identified. "The short-staffing hurts morale. It made you feel as if no one cared.''

The problem goes beyond Ohio. States across the country are fighting the same issues and have explored various ways to address the challenges.

'A difficult environment'

In Cuyahoga County, the jail system has increased its hiring efforts. Still, it has 36 nurses and 10 vacancies. Finding and retaining skilled nurses is a daily dilemma, said Mary Louise Madigan, a county spokeswoman.

"It is a struggle because jails are a difficult environment,'' Madigan said.

The state, meanwhile, has about 480 registered nurses working in prisons, and it has about 50 job vacancies. It posts positions regularly at online job sites. But the problem persists.

The staffing shortage, sick days, vacations and emergencies mean more nurses like Ndematebem and his colleagues at the Franklin Medical Center must work double shifts to provide 24-hour care. Their patients range from those who require short-term care to those with chronic illnesses.

"The criticism we get is that if we just hire more people, then someone wouldn't be making hundreds of thousands of dollars a year in overtime as a nurse,'' said Stuart Hudson, the managing director of health care and fiscal operations for the Ohio Department of Rehabilitation and Correction.

"At the end of the day, we're still going to have overtime, and most folks making those large sums of money are those people who volunteer for it.

"[If more nurses are hired, the overtime] would be spread out. We would still have to pay for the coverage of shifts, whether through straight time or overtime.''

Overtime, of course, is more expensive. The state pays time-and-a-half for regular overtime.

Union leaders say they have pushed administrators for months to hire more nurses, as it would be less expensive for taxpayers.

But retaining the hires, nurses say, especially those with experience, is another issue. Employees who work there said it has become even more trying in recent years, because new hires are often less experienced and unfamiliar with the job and the setting.

All of this has forced prison officials to scramble to find solutions. In Ohio, pay for registered nurses in prisons is competitive with the private sector.

Ndematebem, for example, has 10 years' experience with the state. Most prison nurses with that many years on the job make more than $40 an hour. The state pays starting registered nurses about $55,700 a year, or $26.81 an hour, which is competitive with starting nurses' salaries in mid-sized hospitals.

"From a financial standpoint, working as a nurse in a correctional facility definitely has its perks: The pay and benefits are very good,'' said Jaclyn Lanham, an assistant professor of nursing at Cleveland State University who worked as a nurse practitioner at the Toledo Correctional Institution in 2010 and 2011.

Even with the competitive pay, recruiting nurses to work in prison facilities is difficult.

"People are fearful,'' said Pamela Waite, the director of the Northeast Ohio Nursing Initiative, which seeks to advance nursing programs in the region. "There's a lot of misconceptions about that work. But how often do we go out to nursing schools and talk about the fulfillment of those jobs? Not enough, if we do.''

Lanham, the Cleveland State assistant professor, said the perception of the job must change.

"I found that the people in the correctional system are some of the most appreciative patients that I have ever dealt with,'' she said. "They often didn't have access to care before they went to prison, and they were just happy to get any care that was offered to them.''

Some states, like Connecticut, have forged bonds between prisons and university nursing programs to allow students the chance to intern and work in corrections early in their schooling.

"That shows students what it is like,'' said Deborah Shelton, the director of the Center for Correctional Health Networks, which is part of the University of Connecticut's nursing school. "It is a different atmosphere. But these can be wonderful jobs. Some people have too many biases.''

Compounding the issue in Ohio is that most of state's prisons are located in rural areas, making it even more difficult to recruit medical personnel.

The depth of the problem

Overtime, in most cases, is voluntary. Employees may elect or volunteer to perform it before it is mandated.

Few nurses volunteer like Felicia Nnadi, Ndematebem's colleague at the Franklin Medical Center. From 2012 to 2017, she earned more than $505,000 in overtime.

To get a snapshot of her work schedule, The Plain Dealer, using public records requests, obtained her timesheets for July of 2016.

The timesheets show during that month, she worked double shifts 22 times and handled seven shifts of eight hours.

She took two days off.

"This is something that we monitor,'' Hudson said. "Our management is aware of how much [nurses] are working and the quality of their work.''

Nnadi made $133,406 in overtime in 2016. Repeated attempts to reach her were unsuccessful.

State Sen. Gayle Manning, a Republican from North Ridgeville, is a member of the Correctional Institution Inspection Committee. It serves as a legislative watchdog of the prison system.

"This is something that we need to look at,'' Manning said of the nurses' overtime. "My concern is the quality of care. We trust the Department of Rehabilitation and Correction, but I think a person making $133,000 in overtime in one year is a concern.''

Last year, nursing supervisors accused Nnadi of using poor judgment to document patient care and medical procedures on her patients during June and July, records show. She was placed on administrative leave with pay Aug. 17, and she returned to work in January. She went on disability in May.

In documents filed with the state, Nnadi called the allegations against her "a rather arbitrary and capricious attack on my integrity and professional work at the Franklin Medical Center.''

Ndematebem and Nnadi are not alone in racking up overtime hours. Several nurses at the Franklin Medical Center have totaled more than $200,000 each in overtime since 2012. Repeated attempts to reach them were unsuccessful.

The need for more nurses at the prison is not in question. Nurses at Franklin Medical Center spend their days and nights caring for more than 100 patients, depending on various circumstances.

Some are men like Arthur Schnipper, the state's oldest inmate at 94, he needs full-time medical care. Schnipper, of Dayton, is serving a life sentence for killing his girlfriend more than 35 years ago.

Then there are the two inmates on ventilators, machines that keep them alive. The overtime cost to taxpayers to keep one of them breathing: $1 million.

Controlling the costs

In interviews and published reports, researchers said one way to control medical and overtime costs is to reduce the number of inmates in prisons.

For years, Ohio corrections officials have successfully lobbied county judges to avoid sending low-level felons to prison, a move that keeps the convicted in county jails or treatment, reducing prison costs.

That effort appears to have paid off. In May, the state had the fewest inmates, 49,250, since April 2007, when 49,104 were in prison, records show. Its highest population in recent years came in November 2008, when there were 51,273 inmates.

Families, prison officials and advocates for inmates have urged judges to release elderly inmates who are too feeble to commit another crime or harm society, a method known as compassionate release. States, such as New York, have pushed it as a means to reduce prison medical costs.

In Ohio, the state spends about $200 million a year on health care for inmates. About half of the inpatient and outpatient claims involve older inmates. In 2012, there were 6,821 inmates over 50; today, there are 8,700, an increase of 28 percent.

Scores of state inmates in their 80s struggle to function and require 24-hour-a-day care. But in Ohio, only judges can approve an inmate for compassionate release, and many of them argue that the crimes were so heinous that the inmates should remain in prison.

"To reduce costs, you have to make fundamental changes about who goes to prison and how long they stay there,'' said Michael Jacobson, the director of the City University of New York's Institute for State and Local Governance. He also once oversaw New York's Rikers Island.

"You would save a boatload of money,'' Jacobson said. "Not only are these inmates older, but they are sicker, too. It's a very vulnerable population. The health needs, and the costs of caring for these inmates, are huge.''